Hala Alaouie

The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally

Objective The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review. Data sources The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms. Study selection Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10–29 years. Data extraction Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results. Data synthesis The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels. Conclusions The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

The effect of taxation on tobacco consumption and public revenues in Lebanon

Background Tobacco consumption rates in Lebanon are among the highest worldwide. The country ratified the Framework Convention on Tobacco Control in 2005. A law was passed in 2011 which regulates smoking in closed public spaces, bans advertising, and stipulates larger warnings. Despite international evidence confirming that increasing taxation on tobacco products lowers tobacco consumption, no such policy has yet been adopted: a cigarette pack costs on average US

Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students

1.50. To date no studies in Lebanon have addressed the welfare and public finance effects of increasing taxes on tobacco products. Methods Using the 2005 national survey of household living conditions, we estimate an almost ideal demand system to generate price elasticities of demand for tobacco. Using estimated elasticities and a conservative scenario for expected smuggling, we simulate the consumption and tax revenue effects of a change in the price of tobacco under various tax schemes. Results Increasing taxes on all tobacco products so as to double the price of imported cigarettes would lower their consumption by 7% and consumption of domestically produced cigarettes by over 90%. Young adults (ages 15–30) are more sensitive: consumption would drop by 9% for imported cigarettes and by 100% for domestic cigarettes. Government revenues would increase by approximately 52%. Conclusions The estimated elasticities indicate that an increase in taxes on all tobacco products would lead to a reduction in consumption and an increase in government revenue. Evidence from Lebanon on the effectiveness of increased taxation may help initiate national debate on the need to raise taxes.

Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon

Background Pictorial health warnings are more effective than text warnings in enhancing motivation to quit and not to start smoking among youth. In Lebanon, packs still have only a very small text warning. The aim of this study was to evaluate the perceived effectiveness of pictorial health warnings on cigarette packs among Lebanese youth. Methods This was a cross-sectional study including school students (n=1412) aged 13–18 years recruited from 28 schools and university students (n=1217) aged 18–25 years recruited from 7 universities. A variety of warnings were adapted from other countries. In all, 4 warnings were tested among school students and 18 among university students. Results All pictorial warnings were considered more effective than the current text warning on message-related and impact-related variables, including intentions to quit or not to start smoking among school and university students. Selected examples related to the top-ranked pictorial warnings are: among male non-smoking school students, 81% agreed that the ‘lung’ warning had more impact on their intentions not to start smoking as compared to 57% for the current text warning (p<0.001) with a significant difference compared to the current text warning; among female non-smoking university students, 75% agreed that the ‘economic impact’ pictorial had more impact on their intentions not to start smoking with significant difference as compared to 43% for the current text warning (p value=0.001); finally, the ‘heart attack’ pictorial resulted in 52% of male university students smokers stating they intended to quit as opposed to 20% for the current text warning (p value=0.019). Conclusions The results of the present study add to the general international literature on the impact of pictorial warnings on youth and young adults. This study is also the first to test a non-health pictorial warning about the negative economic consequences of smoking, and to find that such a warning was effective among specific sociodemographic groups.

Arab youth respond to the Lancet Commission on adolescent health and wellbeing

INTRODUCTION Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon, the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated. METHODS This manuscript describes the process evaluation of a school-based intervention to prevent/delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries. RESULTS The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented - with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children’s participation as ‘positive and active’ in 77.9% of the sessions. CONCLUSIONS Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.

A Randomized Controlled Trial of a Theory-Informed School-Based Intervention to Prevent Waterpipe Tobacco Smoking: Changes in Knowledge, Attitude, and Behaviors in 6th and 7th Graders in Lebanon

1964 www.thelancet.com Vol 389 May 20, 2017 The Lancet Commission on adolescent health and wellbeing is a rich compendium of evidence on adolescent health globally, and highlights the importance of youth engagement. Such engagement is vital in the Arab region where youth (15–29 years) comprise about 30% of the population. Young people in this region are exposed to structural violence and conflict that affect every aspect of their lives—a situation that exacerbates the uncertainties of an already tumultuous life stage. Yet young people in the region have used their voices constructively to push for equity and justice. Among these voices is that of the Arab Youth Health Coalition (AYHC) that took part in the regional launch of the Lancet Commission’s report at the American University of Beirut (AUB), Lebanon. Overall, members of the AYHC welcome the evidence set out by the Commission on adolescent health as an opportunity to prioritise topics for research, intervention, and policy in the Arab region. The concepts of the triple dividend and of the importance of secondary education as an investment in adolescent health resonates with AYHC members. But the scarcity of evidence in the Commission from the Middle East is a cause for concern. The AYHC attributes this to the absence of robust Arab youth respond to the Lancet Commission on adolescent health and wellbeing mortality. The CNN technology is exciting in its promise of highly accurate image classification, particularly if it assists in the diagnosis of clinically atypical lesions and we await the findings of further research in this area. However, smartphone applications intended for patientled surveillance and non-expert use must undergo robust prospective validation in a blinded clinical trial and be subject to ongoing safety and efficacy reporting to regulatory authorities to ensure they first do no harm.

Porsche Design's Shisha 2 hits the Lebanese market

Waterpipe tobacco smoking (WTS) is spreading worldwide. Research has indicated health consequences of WTS similar to cigarettes. Prevalence of WTS is high among young people. In Lebanon, current use rates of 35% have been documented among 13–15 year olds. We evaluated a school-based intervention. Method: We conducted a randomized-controlled-trial of a theory-informed WTS intervention. The intervention consisted of ten sessions based on social cognitive theory and the social influences approach. Thirty-one schools participated: 14 intervention and 17 control; a total of 1279 students completed pre and post assessments. We measured knowledge, attitudes and self-reported behaviors related to WTS using Chi-square tests and regression analyses to compare results between the two study arms. Results: The intervention increased knowledge of intervention group compared to control group participants—about WTS constituents and health consequences; and shifted attitudes of intervention group participants to be even more unfavorable towards WTS. We found no impact of the intervention on WTS behaviors. Discussion: The effectiveness of the intervention on knowledge and attitudes supports previous research. The lack of intervention effect on behavior is not surprising given the timing of the post assessment immediately after the intervention, and the social context that was supportive of waterpipe use.

Process evaluation of a community-based mental health promotion intervention for refugee children

Originally an alternative tobacco product confined mostly to the Arab world,1 waterpipe (also called shisha, hookah, argileh, narghile) tobacco smoking (WTS) is increasing globally, and is mainly a youth phenomenon. Youth ever and current smoking rates outpace those of adults in almost every country.2 ,3 Evidence suggests that WTS is associated with several short and long-term health effects.4 A variety of factors have contributed to the rise in WTS, including aggressive marketing tactics5 and lax, non-specific tobacco policies.6 Innovations in design have been reported as attracting women, youth and smokers to WTS.5 Despite increasing rates of waterpipe use globally, the Arab world remains the region with the highest …